Crozet Annals of Medicine: Death Takes a Holiday

2016 was a bumpy ride and I am hoping for fewer surprises this year, although it doesn’t look good so far.

As if to cap off the difficulties of 2016, at the very end of the year we lost two beloved Hollywood icons. Carrie Fisher—Princess Leia—had a cardiac arrest on December 23 at age 60 and died just two days after Christmas. Her mother Debbie Reynolds died the very next day at age 84 of a massive stroke.

These two holiday-related celebrity deaths raised several interesting questions at least among the ER staff working with me over the holidays. Can sick people postpone their deaths sometimes to survive until significant events like holidays happen, as is widely believed, and can spouses or parents will themselves to die after the death of a close loved one, also widely believed?

Researchers have looked at the postponement of death phenomenon from many angles. Sociological research published in the Lancet in 1988 found that among Jewish people the number of deaths was lower than expected in the week before Passover and higher than expected in the week after.

The same author also published in JAMA in 1990 that mortality among Chinese women dips by 35.1 percent in the week before the Harvest Moon Festival and peaks by the same amount (34.6 percent) in the week after.

The author explains that he chose to study mortality among Chinese and a Chinese holiday for two reasons. First, the holiday moves around the calendar, (like Passover in the previous study) thus allowing separation of the effects of the holiday from fixed, monthly mortality effects. Second, the holiday appeals strongly to one (experimental) group and not to others (which can be used as control groups). The dip/peak mortality pattern did not appear in various non-Chinese control groups for whom the Harvest Moon Festival had no significance.

Both of these studies had design flaws and relatively small numbers of patients, a little over 2,000 combined. Additionally a re-analysis of these data, that included an additional 2,437 Asian-American deaths, found no evidence that elderly Asian women were able to prolong their lives until after the festival.

A much larger study published in JAMA in 2004 looked at 309,221 people dying of cancer and found the proportion of persons dying of cancer in the week before Christmas, Thanksgiving, and the individual’s birthday was not significantly different from the proportion dying in the week after the event. They concluded that in a large population sample there was no evidence that people could postpone their death for significant occasions. Of course individuals can behave differently from populations and most of the ER staff still believes people can sometimes hang on to reach a landmark event before dying immediately thereafter.

If that is the case (it is likely not), can the surviving spouse or parent subsequently die of a broken heart as Debbie Reynolds seems to have? There is some good research to answer this question dubbed the “widowhood effect.”

Recent longitudinal studies put the excess mortality of recent widowhood (compared with marriage) among the elderly between 30 percent and 90 percent in the first 3 months and around 15 percent in the months thereafter. There were some notable exceptions however. Deaths of a spouse from Alzheimers disease or Parkinsons disease and some rapidly progressive cancers did not raise the subsequent mortality risk of the surviving spouse. The authors speculate that the spouses had already participated in “anticipatory grief” and were thus protected from sudden shocking grief reactions.

Even more dramatic than the widowhood effect is the “broken heart syndrome” where in the very moments of severe emotional distress people have a life-threatening condition that mimics a heart attack. Unlike a true heart attack, though, these broken-hearted patients have no coronary artery disease and conventional heart attack therapies are not indicated.

The medical term for this is Takotsubo cardiomyopathy. A Takotsubo is Japanese ceramic pot used to catch octopus. Apparently octopus cannot resist crawling into an empty pot and will stay in it even as the pot is hauled into a boat. The Japanese were the first to describe this syndrome in the 1990s and named after it the pot because the heart deforms into a shape that resembles a takotsubo during these attacks.

Broken heart syndrome occurs almost exclusively in menopausal women (90 percent of patients). It is believed to be a spasm of the arteries of the heart in response to adrenalin and other stress hormones.

All of this reminds me how much human beings depend on love to survive. As we enter 2017 and the challenges sure to come in the new year, remember how interconnected we all are. We all need to love and be loved.

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